Case 24 Aging Upper Face



Karen Leong

Case 24 Aging Upper Face

Case 24 (a, b) A 72-year-old female comes to your office complaining of looking tired. She is primarily concerned about her appearance around the eyes and upper face.



24.1 Description




  • Fitzpatrick I skin type



  • Lateral brow ptosis with tattooed brows above supraorbital rim



  • Dermatochalasis of the upper eyelids; pseudoherniation of lower eyelid fat pads



  • Midface descent with a prominent arcus marginalis/infraorbital rim



24.2 Work-Up



24.2.1 History




  • Identify medical conditions that may increase the risk of complications




    • Blepharochalasis, Graves’ disease, glaucoma



    • Previous periorbital and facial procedures




      • Recent laser-assisted in-situ keratomileusis (LASIK) or cataract surgery: Should not undergo blepharoplasty for at least 6 months following procedure



    • History of dry eyes/seasonal allergies




      • Hormone replacement therapy: 70% higher risk of dry eye



24.2.2 Physical Examination (Analysis of the Upper Third of the Face)




  • Forehead analysis: Hairline (brow height), transverse and glabellarr hytids



  • Eyebrow analysis: “Ideal brow”




    • Location: Relation between hair-bearing brow and supraorbital rim



    • Peak: Should be located at or just lateral to the lateral limbus



    • Evaluate for brow ptosis and compensation



  • Upper eyelid analysis




    • Upper eyelid/Iris relationship: Covers 2–3 mm of superior limbus



    • Upper eyelid crease: Female (7–10 mm), male (6–8 mm), Asians (variable but low)



    • Lateral extension of the eyelid crease onto the lateral portion of the periorbital region is a marker of forehead ptosis (Connell’s sign)



  • Lower eyelid analysis




    • Lower eyelid/Iris relationship: Minimal to no scleral show, ideally covers 0.5 mm of the lower limbus



    • Tear trough deformity



    • Malar support




      • Positive vector



      • Negative vector— relative scarcity of skin, hemi exophthalmos



  • Ocular examination (Table 24-1)




    • Eyelid ptosis




      • Patient focuses on a light source with both eyes



      • Margin reflex distance (MRD1): The distance from the pupillary light reflex to the upper eyelid margin (Fig. 24-1)



      • Normal MRD1: 4–4.5 mm



    • Levator excursion




      • Hold brow in resting position. Ask patient to look up and measure excursion of the upper eyelid with a ruler (normal >10 mm)



    • Dermatochalasis: Visual field test to document



    • Visual acuity



    • Dry eyes: Schirmer’s test, Bell’s phenomenon (see Chapter 25)



    • Ectropion/lower eyelid laxity




      • Lower eyelid distraction <7mm, lower eyelid snap test



      • MRD2: Measure the distance from the pupillary light reflex to the lower eyelid margin (Fig. 24-2)



      • Normal MRD2: 5–5.5 mm




























        Table 24.1 Ptosis classification

        Ptosis


        Mild


        Moderate


        Severe


        MRD1


        2–2.5 mm


        1–1.5 mm


        <1 mm


        Levator Excursion


        Good


        >10 mm


        Fair


        5–10 mm


        Poor


        <5 mm


        Abbreviation: MRD, margin reflex distance.


Fig. 24.1 Margin reflex distance (MRD1): Distance from light reflex to upper eyelid. Smaller number is worse.
Fig. 24.2 Margin reflex distance (MRD2): Distance from light reflex to lower eyelid. Larger number is worse.

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 24 Aging Upper Face

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